HESI MENTAL HEALTH EXAM QUESTIONS WITH
COMPLETE SOLUTIONS WITH RATIONALE GUARANTEED
PASS BRAND NEW 2025
The nurse completes a physical assessment. When asked what
brought her to the hospital, the client replies that things just
aren't right and begins to cry. After further conversation, the
client describes her mood as very sad now. She rarely goes out
or invites friends to visit. She admits that she feels like
strangers are saying bad things about her. Sometimes she hears
a man's voice that is a little bit scary.
What is the priority focused nursing assessment? - ANSWER - >
Determine how long the client has been hearing the voice and
what it is saying.
Rationale: Determining if voices are being heard and the type of
voices are priority. The nurse must assess the content of the
auditory hallucinations for the presence of command
hallucinations. Command hallucinations may be telling the
client to harm herself or others.
The client is assessed by the nurse, a social worker, and the
healthcare provider (HCP). Based on their assessments,
hospitalization is recommended for psychotic depression.
,Which behavior is inconsistent with depression? - ANSWER - >
Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent with
depression and are more likely to occur with psychoses.
However, clients may experience a psychotic depression in
which there is evidence of psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-
term involuntary treatment? (Select all that apply. One, some,
or all options may be correct.) - ANSWER - > Unable to meet
basic self-care needs.
Rationale: Involuntary treatment can be initiated if the client is
unable to meet basic self-care needs in such a way that he or
she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to
protect the client if she has a plan to harm herself. It can also
be initiated if she presents an intentional danger to others.
The client signs the treatment form and is admitted to the
mental health unit. During the first days of hospitalization, she
begins antidepressant therapy with fluoxetine 10 mg.
In what classification of drugs is the antidepressant fluoxetine?
- ANSWER - > Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
,What is the major action of SSRI antidepressants? - ANSWER - >
Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely
prescribed than tricyclics for antidepressant therapy. What is
the rationale? - ANSWER - > Tricyclics have more dangerous
side effects.
Rationale: SSRIs are more widely prescribed than tricyclics
because they have fewer side effects, and tricyclics can be
lethal in an overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the
purpose and when to expect therapeutic effectiveness. What
should the nurse tell the client regarding when she will begin to
feel less depressed? - ANSWER - > Generally within 1 to 4
weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant
effects to begin. However, it depends on the individual, and
some clients may feel effects start as soon as 1 week or as late
as 4 weeks. It is suggested that depression occurs when a
depletion of neurotransmitters in the synapse cause the
transmitter receptors to increase. As the antidepressants make
more transmitters available, it takes the receptors several
weeks to return their numbers back to normal and allow
normal synaptic activity.
, The nurse should be aware of common side effects of SSRI
antidepressants such as fluoxetine. Which side effect should be
communicated to the client that commonly occur in clients who
are taking SSRI antidepressants? - ANSWER - > Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well
as genitourinary side effects such as sexual dysfunction, are
common with SSRIs. SSRIs do not have significant
anticholinergic, cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone,
because she reports hearing a "scary voice" upon admission.
Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of
risperidone. Which explanation is best? - ANSWER - >
Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related
to disorders of thinking such as psychosis and behaviors
associated with agitation and disorganization or speech and
behavior.
The nurse is reviewing the client's admission lab work on the
third day of hospitalization. Admission labs include thyroid
profile, urinalysis, chemistry panel, pregnancy test, urine drug
screen, and VDRL (RPR) which tests for venereal disease.
A thyroid profile is important for several reasons. What role do
thyroid levels play in depression? - ANSWER - > Hypothyroidism
can lead to feeling sluggish and depressed.
COMPLETE SOLUTIONS WITH RATIONALE GUARANTEED
PASS BRAND NEW 2025
The nurse completes a physical assessment. When asked what
brought her to the hospital, the client replies that things just
aren't right and begins to cry. After further conversation, the
client describes her mood as very sad now. She rarely goes out
or invites friends to visit. She admits that she feels like
strangers are saying bad things about her. Sometimes she hears
a man's voice that is a little bit scary.
What is the priority focused nursing assessment? - ANSWER - >
Determine how long the client has been hearing the voice and
what it is saying.
Rationale: Determining if voices are being heard and the type of
voices are priority. The nurse must assess the content of the
auditory hallucinations for the presence of command
hallucinations. Command hallucinations may be telling the
client to harm herself or others.
The client is assessed by the nurse, a social worker, and the
healthcare provider (HCP). Based on their assessments,
hospitalization is recommended for psychotic depression.
,Which behavior is inconsistent with depression? - ANSWER - >
Hearing a man's voice.
Rationale: Auditory hallucinations are inconsistent with
depression and are more likely to occur with psychoses.
However, clients may experience a psychotic depression in
which there is evidence of psychosis.
The nurse asks the client to sign the consent for treatment.
If the client refuses treatment, which behaviors justify short-
term involuntary treatment? (Select all that apply. One, some,
or all options may be correct.) - ANSWER - > Unable to meet
basic self-care needs.
Rationale: Involuntary treatment can be initiated if the client is
unable to meet basic self-care needs in such a way that he or
she is a danger to self.
States she has a plan to harm herself.
Rationale: Short-term involuntary care may be initiated to
protect the client if she has a plan to harm herself. It can also
be initiated if she presents an intentional danger to others.
The client signs the treatment form and is admitted to the
mental health unit. During the first days of hospitalization, she
begins antidepressant therapy with fluoxetine 10 mg.
In what classification of drugs is the antidepressant fluoxetine?
- ANSWER - > Selective serotonin reuptake inhibitor (SSRI).
Rationale: Fluoxetine is an SSRI antidepressant.
,What is the major action of SSRI antidepressants? - ANSWER - >
Increase availability of serotonin.
Rationale: The major action of SSRIs is to selectively inhibit the
reuptake of serotonin and increase the availability of serotonin.
The nurse understands that SSRIs are now more widely
prescribed than tricyclics for antidepressant therapy. What is
the rationale? - ANSWER - > Tricyclics have more dangerous
side effects.
Rationale: SSRIs are more widely prescribed than tricyclics
because they have fewer side effects, and tricyclics can be
lethal in an overdose because they are cardiotoxic.
When the client receives fluoxetine, the nurse must explain the
purpose and when to expect therapeutic effectiveness. What
should the nurse tell the client regarding when she will begin to
feel less depressed? - ANSWER - > Generally within 1 to 4
weeks.
Rationale: In general, it takes 2 to 4 weeks for antidepressant
effects to begin. However, it depends on the individual, and
some clients may feel effects start as soon as 1 week or as late
as 4 weeks. It is suggested that depression occurs when a
depletion of neurotransmitters in the synapse cause the
transmitter receptors to increase. As the antidepressants make
more transmitters available, it takes the receptors several
weeks to return their numbers back to normal and allow
normal synaptic activity.
, The nurse should be aware of common side effects of SSRI
antidepressants such as fluoxetine. Which side effect should be
communicated to the client that commonly occur in clients who
are taking SSRI antidepressants? - ANSWER - > Gastrointestinal
disturbances.
Rationale: GI disturbances such as nausea and diarrhea, as well
as genitourinary side effects such as sexual dysfunction, are
common with SSRIs. SSRIs do not have significant
anticholinergic, cardiovascular, or sedative side effects.
The client also begins an atypical antipsychotic, risperidone,
because she reports hearing a "scary voice" upon admission.
Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of
risperidone. Which explanation is best? - ANSWER - >
Risperidone will help the think more clearly.
Rationale: Antipsychotic medications target symptoms related
to disorders of thinking such as psychosis and behaviors
associated with agitation and disorganization or speech and
behavior.
The nurse is reviewing the client's admission lab work on the
third day of hospitalization. Admission labs include thyroid
profile, urinalysis, chemistry panel, pregnancy test, urine drug
screen, and VDRL (RPR) which tests for venereal disease.
A thyroid profile is important for several reasons. What role do
thyroid levels play in depression? - ANSWER - > Hypothyroidism
can lead to feeling sluggish and depressed.
